Baby Peter 'failed by NHS staff who saw him 35 times'
Baby Peter was failed by NHS doctors and nurses who saw him 35 times before his death but did not act "fast enough or smart enough", the healthcare regulator said.
By Matthew Moore
Systemic failings at three hospital trusts including Great Ormond Street caused medical professionals to miss signs of abuse that – if followed up – could have saved the boy's life.
In a damning report, the Care Quality Commission identified staff shortages, poor communication, insufficient training and failures to stick to correct procedures at Middlesex University Hospital NHS Trust, Haringey Teaching Primary Care Trust and Great Ormond Street Hospital for Children NHS Trust.
When Baby P underwent a paediatric assessment on Aug 1 2007 – two days before his death – there were just two consultants working at St Ann's Hospital in Tottenham which should have four in post. Due to staff shortages, the appointment had been delayed by 12 weeks.
Dr Sabah Al-Zayyat, who has since been suspended by her employer Great Ormond Street after failing to spot the 17-month-old boy had a broken back, conducted the examination without details of his previous hospital visits or full knowledge of his child protection reports.
"This is a story about the failure of basic systems," said Cynthia Bower, chief executive of the CQC.
"There were clear reasons to have concern for this child but the response was simply not fast enough or smart enough. The NHS must accept its share of the responsibility."
Today's report was ordered by Alan Johnson, the Health Secretary, last December to investigate what lessons could be learned by the NHS from the case of Baby P, who died on Aug 3 2007 after enduring months of physical abuse from his mother, her boyfriend and their lodger in Haringey, north London. Publication was delayed until after the culmination of criminal proceedings.
The review makes a series of recommendations and will check on the trusts' progress in six months, with the possibility of sanctions if they fail to improve.
Although the CQC was not authorised to propose disciplinary action, the report will increase pressure on the trusts to punish the managers responsible.
Yesterday it was disclosed that four senior doctors a St Ann's raised concerns about the "very high risk" of child protection failings at the hospital in 2006, but their letter was ignored by bosses.
The head of Haringey Council children's services, Sharon Shoesmith, and her deputy were sacked after a report into how social workers let down Baby Peter, but so far only two front-line medical staff – Dr Al-Zayyat and the boy's GP Dr Jerome Ikwueke – have been suspended. The CQC criticised Dr Ikwueke for failing to spot trends in the toddler's regular hospital visits despite holding his medical records.
A spokesman for Great Ormond Street Hospital, which operates paediatric services for Haringey and North Middlesex University trusts, said that it had already implemented many of the recommendations.
"Great Ormond Street Hospital reiterates the public apology we made in November regarding Peter's tragic death. We're truly sorry Peter suffered and died."
But he added: "None of the reports, reviews, investigations or any evidence we have seen suggests that disciplinary action is required against any of our current staff."
NHS Haringey and Middlesex University Hospital Trust said that they welcomed the recommendations and were committed to improving services.
Over his life Baby Peter had 34 contacts with healthcare professionals employed by the three trusts. He was also treated once by Whittingdon Hospital NHS Trust, but the CQC found its child protection systems to be appropriate.
The regulator said it was "concerned" that all of the trusts had previously declared that their child protection provisions met national standards. It has launched a national review of all NHS trusts to evaluate their compliance procedures.
Three more children being let down by the NHS while they concentrate on protecting their negligent, criminal parents
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